a blog of books every doctor should read

The Citadel

The Citadel is the fictional account of a newly qualified doctor. It details the personal and professional challenges he faced as he progresses from humble general practice in rural Wales, to lucrative private practice in central London. His attempt to balance high ethical standards with the demands of a successful medical practice is both heartwarming and tragic. The book explored how Manson’s moral judgments determined his fate.

The author, a physician, masterfully portrays the emotions and doubts that characterise clinical practice, and depicts the professional and social pressures that threaten medical careers. He illustrates the uncertainties that accompany clinical decision-making; for example, when Mason was assessing his first case, he ‘was conscious of his nervousness, his inexperience, his complete unpreparedness, for such a task…. attempting painfully to generate a confidence he did not feel…’ (page 11). The book also illustrates the cautious satisfaction that comes with solving tricky clinical cases, such as when Manson says ‘he must not be a plunger, wildly leaping to conclusions. He must go cautiously, slowly, be sure’ (pages 60-61).

The Citadel is about the idealism and enthusiasm of early medical careers, and the disillusionment with the medical establishment that follows. It is about peer pressure to climb up the social ladder, and the consequences of blindly pursuing material goals. With Manson, his youthful zeal resulted in subversive acts and clandestine research, and his disillusionment led to a series of outspoken protests and resignations.

The book’s highlight is its masterful portrayal of the gradual transformation of the protagonist’s character. In depicting this, the author’s prose is nothing short of brilliant. Take for example Manson’s loyal wife reflecting on her husband’s altered personality:

‘…His idealism had been pure and wonderful, illuminating both their lives with a clear white flame. Now the flame had turned yellower and the globe of the lamp was smudged‘ (page 299).

The book also takes us deep into the mind of Manson, exploring his inner conflicts as his circumstances change rapidly. Take these examples:

Manson is undergoing a ‘struggle between all that he believed and all he wished to have’. (page 271).

‘He was sick of failure, tired of being a three-and-sixpenny hack. He wanted to get on, to succeed. And he would succeed at all costs’ (page 271)

‘In his eagerness for success he forgot how contrary was his progress to all he had hitherto believed’ (page 276).

‘On and on rushed the state of his success, a bursting dam sweeping him irresistibly forward in an ever-sounding, ever-swelling flood’ (page 349).

The author’s unique writing style is evident in the sparing, but precise, representation of characters. Take this sketch of Mason’s clinical examiner:

‘Gadsby was a sparse undersized man with a ragged black moustache and small mean eyes. Recently elected to his Fellowship, he had none of the tolerance of the older examiners, but seemed to set out deliberately to fail the candidates who came before him’ (page 172).

The author also has an uncanny ability to build and sustain tension, illustratively describing dramatic scenes. This shines through in his graphic depiction of medical and legal scenes which greatly enhanced the story.

One of the book’s key lessons is the importance of professional conduct. The author portrayed this in many places such as when Manson ‘had far too much upon his mind, too many important cases in his practice, to be able to concentrate upon obscure signs which might not even exist. No one knew better than he how long it took to examine a case properly. And he was always in a hurry’ (page 305). The author also showed his concern for clinical governance, such as when the protagonist, bemoaning a colleague’s incompetence, says ‘… there ought to be compulsory post-graduate classes to be taken every five years’ (page 189).

This is a very thought-provoking work with several moral lessons woven into the fabric of an excellent story. The author’s writing is lucid and devoid of long and unnecessary details. He clearly set out to promote ideal professional values such as integrity, hard work and determination, and he also emphasised the evils of greed and egotism. And he did all this successfully.

OVERALL ASSESSMENT

This is a heart-warming and tragic tale. It has drama and adventure intertwined with strong moral lessons for which I recommend it to all doctors.